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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date `� L� .` OFFICE USE ONLY <br /> To: San Joaquin County J08# 7 3AP REF# <br /> Department of Public Works APN _ CR# <br /> n _ EXP.DATE 5—L -( S <br /> T• C° <br /> )R-A)i A V V 19 I Eg I QE VALID -Z TO DRIVEWAYS: <br /> (ApplicantNarM) STREET _ -kAl .lic4 AV <br /> AREA -f QUAD <br /> 1�D 0 E . Q9 FJ9 Y E-7-1 'f'• ST TYPE �'et <br /> (il0iailing Address) FORMS 14114/ -2 Gj <br /> O N <br /> NOTES <br /> ATO L 1 � <br /> (City,State,Zip Code) <br /> coy <br /> (Area Code e Telephone dumber) <br /> Sketch(Detailed pians may be submitted) <br /> s <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County High Right-of-Way on <br /> the SOU r it side of E1)GL(D approximately ( Q ile <br /> of r 4p,6 A VP-h by performing the following work(description of work): <br /> 20.20 LJ. E U CL4 A Vr:--. ACCT' 1© QD© <br /> rnR l rJ EPA(IY, 3 r Y-- 0500 <br /> WT-1 3'x 6° ACr iD <br /> Work will commence on or about Zit t for proximately days. <br /> i J lj <br /> t,the undersigned,certify that I am the owner of the respective props , ram ualifi d to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> -AL4Signature of AppElcaf Tifle qtr <br /> M:ICENTRALSEFZOCESlCLERICAL.MBSVWKN7ASTIILPSSICROACN9IEMTPERMfTAPPI.ICAIIONAOC(09113) 1 <br />